How does Tierney evaluate my baby’s head shape?


Tierney clinicians utilize multiple clinical criteria when evaluating each head shape.These criteria have been published in peer reviewed journals and are supported as repeatable and reliable for the purpose of creating a treatment plan for deformational plagiocephaly.


Method: Evaluation using clinical observation

Tool: Argenta Clinical Classification Scale


Journal Article References:

Argenta L, David L, Thompson J. Clinical classification of positional plagiocephaly. J Craniofac Surg. 2004 May;15(3):368-72. doi: 10.1097/00001665-200405000-00004. Erratum in: J Craniofac Surg. 2004 Jul;15(4):705. PMID: 15111792.

Branch LG, Kesty K, Krebs E, Wright L, Leger S, David LR. Argenta clinical classification of deformational plagiocephaly. J Craniofac Surg. 2015 May;26(3):606-10. doi: 10.1097/SCS.0000000000001511. PMID: 25901672.


The Argenta classification scale provides specific descriptions for five (5) types of deformational plagiocephaly and three (3) types of deformational brachycephaly. This quick and easy qualitative assessment can be performed in the clinic by visual assessment alone and does not require special tools or equipment.





Method: Evaluation using digital head scan

Tool: CHOA Scale


Journal Article References:Plank LH, Giavedoni B, Lombardo JR, Geil MD, Reisner A. Comparison of infant head shape changes in deformational plagiocephaly following treatment with a cranial remolding orthosis using a noninvasive laser shape digitizer. J Craniofac Surg. 2006 Nov;17(6):1084-91. doi: 10.1097/01.scs.0000244920.07383.85. PMID: 17119410.

Holowka MA, Reisner A, Giavedoni B, Lombardo JR, Coulter C. Plagiocephaly Severity Scale to Aid in Clinical Treatment Recommendations. J Craniofac Surg. 2017 May;28(3):717-722. doi: 10.1097/SCS.0000000000003520. PMID: 28468155.


Children’s Healthcare of Atlanta is a worldwide leader in evidence based clinical practice. As such, CHOA utilized the STARscanner by Orthomerica to create and validate a plagiocephaly scale based on STARscanner outcomes data. Tierney utilizes the CHOA scale and the technology based on this scale, the STARscanner and SmartSoc scanning systems.





Tierney Cranial Remolding Orthosis Treatment Plans are Evidence-Driven.


Tierney follows several evidence-based clinical protocols when determining the appropriate treatment plan for each patient. An example of one of the treatment guidelines, from the Congress of Neurological Surgeons, is below.

CNS GuidelinesThe American Academy of Pediatrics has endorsed the Congress of Neurological Surgeons (CNS) publication titled Evidence Based Guidelines for the Treatment of Pediatric Positional Plagiocephaly. A summary of the recommendations includes but is not limited to:


  • Pediatricians are able to make a definitive diagnosis of deformational plagiocephaly by physical examination alone in most cases.
  • Repositioning is an effective treatment for deformational plagiocephaly, and is most relevant to young infants, usually four (4) months of age or younger.
  • Physical therapy may be required for some infants with neck muscle involvement.
  • Cranial remolding headbands are recommended for infants at least four months of age with persistent moderate to severe plagiocephaly after a course of conservative treatment, e.g. repositioning, tummy time, physical therapy. Cranial remolding orthoses are also recommended for older infants with moderate to severe plagiocephaly, when repositioning efforts are no longer effective.


The CNS publication also notes that infants with a more severe deformity yield better clinical outcomes when orthotically managed at an earlier age.



Tierney’s Cranial Remolding Program

Regardless of the effort and intent, not all infants respond to even the most consistent repositioning and therapeutic techniques. In the event that a CRO is still indicated, Tierney’s credentialed practitioners provide cranial remolding orthoses treatment to resolve the unresolved cranial flattening. Our practitioners bring value to the orthotic treatment program with a strong background in anatomy, biomechanics, material science, and patient care. We work closely with other craniofacial team members to help your baby achieve optimal correction and results with helmet therapy.


Tierney Uses the Orthomerica STAR® Family of Cranial Remolding Orthoses


The STAR® Family of Cranial Remolding Orthoses has been used to treat positional Plagiocephaly, Brachycephaly, Scaphocephaly and other head shape deformities in infants 3-18 months of age since 2000. Over 600,000 infants have been successfully treated with the STARband, the first cranial remolding orthosis with FDA clearance available to O&P practitioners across the United States and around the globe.


Orthomerica’s cranial products are provided in more than 800 clinics in the United States and many more worldwide.


Tierney Employs STARband Specialists and Orthomerica AllSTARs


Our STARband cranial clinicians have extensive experience and expertise in the management of infants with skull deformities. Referrals to our clinicians ensure the most thorough evaluation process, use of advanced scanning technologies, and documentation of anthropometric measurements. This is combined with exceptional clinical experience to provide the most appropriate treatment recommendations and follow-up programs.


Orthomerica developed the AllSTAR clinical network to recognize and promote the clinical expertise of orthotic clinicians who specialize in the management of infants with skull deformities. This program creates the most extensive global footprint of cranial specialists.The AllSTAR clinicians focus on evidence-based medicine and contribute clinical outcomes data that is used to quantify the efficacy of STARband cranial programs. AllSTAR membership is maintained through continuing education, standardized clinical protocols, provision of excellent patient care, and ongoing professional contributions to this medical specialty.


How do I prevent and/or treat it?


As such, there are several ways to combat deformational cranial flattening, examples of which you can obtain on our website or HERE- CHOA resources. If indicated, our clinical team will work with each family to create an individual plan for conservative treatment of the infant’s head shape. Examples of our conservative approaches include:


  • Specialized directed repositioning of the infant’s head and neck
  • Supine head positioning modifications during waking hours
  • Sleep surface modification using the Perfect Noggin**


Additionally, Tierney fully embraces a team approach to conservative treatment and encourages external referrals, including:


  • physical therapy with home stretching exercises
  • Specialized infant Chiropractic care


A clinical recommendation for STARband cranial remolding orthosis treatment is made only for infants with moderate to severe skull deformities which remain after conservative efforts have failed to improve the head shape.


At Tierney, we believe that not all infants will need a cranial remolding orthosis.


A Cranial Remolding Orthosis (CRO), or helmet, functions in a very simple manner. Remember that initially the weight of the cranium lying in various positions was enough to change the head shape. A helmet functions to alter the direction of the ever-growing infant brain away from the existing prominences, or bossing, and into the areas where flattening exists. To achieve correction, a helmet will both provide a slight hold or restriction in the areas where the skull is full or prominent while also providing a void space and removing the hold on the skull where flattening is already present. The existing cranial growth continues normally and there is no restriction of brain expansion. Helmets are effective as long as there is cranial growth remaining, and the rate of correction is proportionate to the rate of growth. Younger patients (4-6 months) will correct much faster than those over 9 months of age while children as old as 12-18 months of age can still have some correction of flattening, but the process may take as long as 6 to 8 months.

Cranial Remolding

What is Plagiocephaly?


Deformational plagiocephaly is estimated to affect approximately 20% of all infants to varying degrees.


Today’s infants tend to spend an extraordinary amount of time on their backs, both during sleep and awake time. The 1992 Back to Sleep recommendation was widely followed in Western medicine and culture, and is credited with an estimated 40% reduction in the incidence of sudden infant death syndrome in the United States. An unforeseen consequence of the campaign was a rise in posterior cranial flattening. The rise in combination carriers/car seats and other positional devices have also made it much more common for infants to remain supine for up to 20 hours each day through the first 4 months of age. This early and sustained positioning has proven detrimental to the proportional and symmetrical growth of the skull.


Deformational plagiocephaly is the visual flattening that results from consistent contact pressure in one area of the cranium which effectively restricts growth in that region. Significant asymmetric growth of the cranium is often accompanied by compensatory facial asymmetry, specifically an anterior shift of the ipsilateral forehead, ear, and cheek on the same side as the posterior flattening.


The primary driver for deformational cranial flattening is limited head rotation during supine positioning. This can be related to neck muscle imbalances (torticollis), developmental factors (hypotonia, macrocephaly, genetic anomalies, etc), and/or related to the supine positioners themselves.

Since 2014, Tierney Orthotics and Prosthetics has become the Winston-Salem, North Carolina area’s preferred source for orthotics, prosthetics, diabetic footwear, mastectomy prosthetics, and shoe inserts.